No.

Induk Santri / Santriwati : _________________________

A. KETERANGAN SANTRI / SANTRIWATI

1. Nama Santri / Santriwati Lengkap .......................................:

2. Nama Panggilan ...................................................................:

3. Tempat / Tgl Lahir ................................................................:

4. Jenis Kelamin .......................................................................:

L/P
5. Jumlah Saudara ....................................................................:
……………………………….. anak ke
6. Alamat ..................................................................................:

............................................................................................

B. KETERANGAN ORANG TUA

1. Nama Orang Tua ..................................................................
a. Ayah .....................................................................................:

b. Ibu ........................................................................................:

2. Pendidikan ...........................................................................
a. Ayah .....................................................................................:

b. Ibu.........................................................................................:

3. Pekerjaan .............................................................................
a. Ayah .....................................................................................:

b. Ibu ........................................................................................:

4. Alamat Orang Tua ................................................................:

............................................................................................
No. Telephon : ……………………………….. HP : ........................

C. KETERANGAN WALI
1. Nama Wali ...........................................................................:

2. Alamat Wali..........................................................................:
.............................................................................................
No. Telephon : ………………………………..HP : ....................................................................................
3. Hubungan dengan Anak : a. Kakek ............................b.
Nenek c. Paman
d. Lainnya sebutkan ...........................................................

D. PERKEMBANGAN SANTRI / SANTRIWATI

1. Khotaman Al-Quran / Tidak Khotam
a. Tanggal .................................................................................:
 b. Syahadah No ........................................................................:

2. Melanjutkanke
a. Madrasah Diniyah ................................................................:

b. Pondok Pesantren ................................................................:

c. Lainnya .................................................................................:

Pass Foto
3x4 cm